Rehospitalizations Following Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction: Results From a Multi-Center Randomized Trial.

BACKGROUND: Rehospitalizations (RHs) after ST-elevation myocardial infarction carry a high economic burden and may deteriorate quality of life. Characterizing patients at higher risk may allow the design of preventive measures. We studied the frequency, reasons, and predictors for unplanned cardiac and noncardiac RHs in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. METHODS AND RESULTS: In this post-hoc analysis of the COMFORTABLE AMI (Comparison of Biolimus Eluted From an Erodible Stent Coating With Bare Metal Stents in Acute ST-Elevation Myocardial Infarction; NCT00962416) trial including 1137 patients, unplanned cardiac and noncardiac RHs occurred in 133 (11.7%) and in 79 patients (6.9%), respectively, at 1 year. The most frequent reasons for unplanned cardiac RHs were recurrent chest pain without evidence of ischemia (20.4%), recurrent chest pain with ischemia and coronary intervention (16.9%), and ischemic events (16.9%). Unplanned noncardiac RHs occurred most frequently attributed to bleeding (24.5%), infections (14.3%), and cancer (9.1%). On multivariate analysis, left ventricular ejection fraction (22% increase in the rate of RHs per 10% decrease; P=0.03) and angiographic myocardial infarction Syntax score (34% increase per 10-point increase; P=0.01) were independent predictors of unplanned cardiac RHs. Age emerged as the only independent predictor of unplanned noncardiac RHs. Regional differences for unplanned cardiac RHs were observed. CONCLUSIONS: Among ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention in the setting of a randomized, clinical trial, unplanned cardiac RHs occurred in 12% with recurrent chest pain being the foremost reason. Unplanned noncardiac RHs occurred in 7% with bleeding as the leading cause. Left ventricular ejection fraction and Syntax score were independent predictors of unplanned cardiac RHs and identified patient subgroups in need for improved secondary prevention. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00962416.

Deep propofol sedation for vacuum-assisted bite-block immobilization in children undergoing proton radiation therapy of cranial tumors.

BACKGROUND: Vacuum-assisted bite-block immobilization of the head is a reliable technique for reproducible precise head positioning as used for proton radiation in adults. We report preliminary experience using deep propofol sedation without an artificial airway in children undergoing proton radiation of cranial tumors requiring vacuum-assisted bite-block immobilization. METHODS: Sedation was started with a bolus of i.v. midazolam followed by repeated small boluses of propofol as required to tolerate bite-block insertion and patient positioning. Sedation was maintained by continuous propofol infusion until removal of the bite block. Oxygen was administered by a nasal cannula. SpO2, endtidal CO2 taken at the nose and respiratory adverse events such as coughing, bucking, airway obstruction, regurgitation or aspiration were recorded. Data are mean+/-sd. RESULTS: Ten children aged 2.6+/-0.8 years were treated to date. For each child, cumulative 26.7+/-1.9 radiation fractions were administered. Propofol dose administered for induction, bite-block insertion and patient positioning was 3.9+/-0.5 mg.kg(-1). Time from insertion to removal of the bite block lasted 48.3+/-6.2 min. Endtidal CO2 values were 5.6+/-0.8 kPa (43+/-7 mmHg) and SpO2 values were 98.3+/-1.9% with spontaneous breathing, supplemental oxygen and bite block inserted. No respiratory adverse events occurred during the 267 sedation procedures performed. CONCLUSION: Deep propofol sedation without the use of an artificial airway is an interesting technique for vacuum-assisted bite-block immobilization in young children undergoing precise radiation therapy of cranial tumors. However, simultaneous individual anesthetic challenges require pediatric anesthesiologists highly experienced with the pediatric airway, clinical alertness and closed monitoring.

Distribution patterns of beta- and gamma-herpesviruses within Waldeyer's ring organs.

The Waldeyer's ring designates a functional unit of lymphoid tissue within the pharynx including the adenoids and tonsils. To gain insight into distribution patterns of beta- and gamma-human herpesviruses (HHVs) and their potential mutual influences at their natural portal of entry, quantitative polymerase chain reaction (qPCR) assays were applied to adenoids and tonsils obtained from 30 children. DNA of Epstein-Barr virus (EBV), cytomegalovirus (CMV), HHV-6, HHV-7, and HHV-8 was detected in adenoids, tonsils, or both of 24 (80%), 19 (63%), 23 (77%), 23 (77%), and 0 (0%) children, respectively. EBV, CMV, HHV-6, and -7 localized in both adenoids and tonsils from 92%, 37%, 52%, and 70% of children, respectively, with the virus detectable by qPCR. The amount of EBV was 2-10-fold higher than of other HHVs and correlated in autologous organs (P = 0.01) as did the amount of HHV-7 (P = 0.002). The amount of CMV correlated with the HHV-6 amount in adenoids (P = 0.028) and tonsils (P = 0.007), and with the amount of HHV-7 in adenoids (P < 0.01). Levels of HHV-6 DNA were lower in adenoids with detectable CMV DNA than in adenoids without detectable CMV DNA (P = 0.0062). Inversely, CMV and HHV-7 levels were higher in adenoids with than in adenoids without detectable EBV DNA (P = 0.019 and P = 0.039, respectively).Thus, beta- and gamma-HHV exhibit distinct distribution behaviors in Waldeyer's ring organs and seem to interact. This may be of medical importance in immunocompromised hosts who are likely to reactivate HHVs causing severe morbidity and death.